Rumination and Rumbling on Vascular Access...

Our first post is a big one -- and sets the bar high because it begins with a conversation regarding our landmark product: The Michigan Appropriateness Guide to Intravenous Catheters (MAGIC). Here's excerpts of our thoughts regarding this project.

Q: What motivated this project? A: Vascular access is literally the most common procedure performed in hospitalized patients. It is invasive, costly, can lead to finite harm -- and yet the research behind it has not been well organized. When you begin to look at practice, you realize people are acting in very different ways with respect to who gets an IV, who gets a central line, who gets a PICC. This variation brought our attention to the topic.

Q: How do you think current use compares to what was deemed appropriate by the panel? A: A big problem is defining what current use is. We now have 47 hospitals across Michigan working collaboratively to collect data regarding use of PICCs and outcomes. This experience - now one year old - shows large gaps between what is deemed appropriate and current practice. A classic example: one of the recommendations deemed appropriate by the panel was [to] not place PICCs for durations of less than 5 days, unless you need to give an irritant or a vesicant. Yet in data encompassing over 5,000 PICCs, about 25% are removed within 5 days. It's over 1,000 devices when you do the math. It's astonishing. Q: Were you surprised by any of the conclusions the panel came to? A: The surprise wasn't so much the conclusions, as much as the process. It was incredible how extremely collaborative it was. I was also surprised by the intense debate that transpired in specific areas—especially on when and which device to use. The evidence in this area is fragmented and much of it has been generated by nurses, interventional radiology and others. As you can imagine, with the cultural shifts between nursing and physicians, there's lots of disagreement about what device, when and why.

Q: What were the biggest areas of disagreement among the participants? A: One of the disagreements we had early on was the use of PICCs for short-term periods in patients who had veins that were difficult to access or needed frequent blood draws. The evidence here isn't clear. Ultimately the panel agreed devices other than PICCs may be safer and could achieve these goals. But the process of discussion and deliberation was intense. Q: How do you get these recommendations into practice? A: We want to start testing MAGIC in our real-world laboratory, the Hospital Medicine Safety Consortium, which now consists of 47 hospitals in Michigan. We want to figure out what works, what doesn't and why. What we ideally would like to do is create a toolkit, "Here are the top 5 recommendations from this panel of ways to improve your practice around venous access and PICCs," and actually make it simple. Hospitalists can choose 1, 2, 3, maybe all 5 of these recommendations and then track the impact of these changes. Q: Do you see appropriateness of PICCs eventually being a quality measure? A: Yes - not just PICCs but venous access in general. What we would like to do, especially for our collaborative, is give hospitals a dashboard. We have started doing this for benchmarking purposes … feeding back things like the number of PICCs that were placed for less than 5 days, how many PICCs developed CLABSI [central line-associated bloodstream infection], how many developed VTE [venous thromboembolism].

Q: Do you think these recommendations will change much based on future research? A: I sincerely hope so. This is an important first step, but it's just that, a first step. There are going to be newer devices that come out that we haven't even thought about or included. There will be new evidence regarding harm and benefit, and if and when evidence suggesting one device may be better than another, then we should look back on MAGIC and modify recommendations. MAGIC is a great way of organizing what we know, but I sincerely hope it's a living document. Only then will it serve to best take care of our patients.